Cooperative Boating Accident InvestigationPresented to NASBLASeptember 30, 2009, Corpus Christi, TexasBy Rob Henry

Presentation OverviewBrief description of NTSBNTSB marine accident investigationNTSB safety recommendationsApril 12th Jacksonville, Florida boating accidentOpportunities and challenges

42 Years Ago - 1967-2009Created in 1967 by the Congress with the authority to investigate aviation, marine, rail, highway, pipeline, and hazmat transportation accidents. In 1974,Congress made the NTSB completely independent of the DOT.

Mission of the NTSBThe NTSB is charged with Determining the probable cause(s) of transportation accidents, and Making recommendations to prevent their recurrence.

The Safety Board Members The Safety Board consists of five Members, appointed by the President, with the advice and consent of the Senate. Members serve 5-year staggered terms.

Authority to Investigate Marine AccidentsMayInvestigate Any Major Marine Accident Involving a Foreign Vessel Which Occurs in U. S. WatersMay Investigate Any Major Marine Accident Involving a U.S. Ship Anywhere in the WorldShall Investigate Any Collision Between a Public and a Non-Public VesselMay Investigate Other Marine Accidents of a Recurring Nature

Major Marine Accident DefinitionSix or More Lives Lost Total Loss of a Self-Propelled Vessel of 100 Gross Tons or more$500,000 or more in Property DamageSerious Threat to Life, Property, or the Environment From the Release of Hazardous Materials

There Are Many Different Types of Marine AccidentsThe Office of Marine Safety Investigates. . .

Collisions

Groundings

Fires

Explosions

And Last,

But Not Least . . .

We Also Investigate

Sinkings

There are Many Different Types of Vessels Involved in Marine Accidents, Including . . .

Foreign Passenger Ships

Domestic Passenger Vessels

Commercial Fishing Vessels

Offshore Service Vessels

Offshore Supply

Mobil Offshore Drilling Units

Tankships

Tugboats

Towboats

Barges

Containerships

And Last, But Not Least,

Recreational Boats

Number of AccidentsIn An Average Year, About 6000 Commercial Vessel Accidents Reportable To The Coast GuardAbout 30-40 Of These Accidents Meet At Least One Criteria For Major Marine AccidentNTSB Investigates Approximately 6-8 Major Marine Accidents Each Year

Independent Investigation Under NTSB RulesAccident Has Significant Safety IssuesAccident Has High Loss of Life or Major PollutionAccident Has Wide Public Interest, orAccident Involves Public Vessel or Major Coast Guard Function

Under NTSB RulesLaunch “GO TEAM”On 24-Hour Call365 Days A YearEnroute In 2 Hours of Notification

Typical Go TeamInvestigator-In-ChargeMarine Engineering Group ChairmanHuman Performance Group ChairmanSurvival Factors Group ChairmanOther Group Chairmen, As NecessaryFire ScienceMetallurgyHazardous Materials

Member LaunchSafety Board Member May Launch With Team, Depending Upon SeriousnessTypically will include a public affairs officer and a family assistance specialist.

Investigation to ReportOn scene investigation usually takes one to two weeksReport development will take a year for a complex major marine investigation

Board Meeting The Board Members conduct a public meeting to discuss and approve a final report on the accident. The final report includes conclusions, a statement of probable cause, and recommendations.

Safety RecommendationsSafety recommendations are the Board’s most important product They are developed to remedy system, hardware, operational or policy failures identified during investigations

Safety Recommendations Recommendations are issued to DOT and its modal administrations, DHS (US Coast Guard), manufacturers, transportation operators, trade associations, labor unions and state and local governments

Major AccomplishmentsImproved Fire Protection on Cruise ShipsSprinkler SystemsSmoke DetectorsImproved Lifesaving Equipment on Commercial Fishing VesselsLife raftsSurvival SuitsEPIRBsImproved Navigation SafetyBridge Resource Management TrainingStandardization of Integrated Bridge Navigation Systems

“Most Wanted” ListSafety recommendation issuearea selected by the Board for intensive follow-up because it:Will impact or enhance safety on the national levelHas high public visibility and interestCan be implemented in a reasonable period of time; andIs an area that would benefit from this special form of encouragement

NTSB Safety Initiatives1993 Recreational Boating Safety Study1998 PWC Safety Study2006 public forum on life jackets2006 sole state waters seminar

Prior NTSB Boating AccidentsJuly 3, 1999, Bayport, MN - Advantage & Bayliner - 5 of 5 fatalDecember 29, 1997, Charleston, SC – Morning Dew - 4 of 4 fatalAugust 21, 1994, Juneau, AK – Questar - 1of 2 fatal

Allision of the Unnamed Recreational Vessel (Crownline 22) with the towing vessel Little Man II, near Palm Valley, FloridaApril 12, 2009

Arial photos

Arial photos

M/V Little Man II - damage

Crownline 22 damage

Consequences of Accident14 Passengers – none ejected5 fatalities9 seriously injured3 medevaced to local hospitalsNo one walked away from the accident unscathedUnique opportunity to conduct a Federal-State Cooperative boating accident investigation

LaunchEarly decision between NTSB and USCG on Federal primacyDuty Board Member to launchGo TeamNotification of launch to Florida FWCLead investigator contactPublic affairs contactTeam arrival Jax and press conference

Arrival On SceneSet Up Command PostIIC Holds Organizational MeetingDesignates Parties to the InvestigationExplains Ground RulesForms Investigative GroupsGroups Disperse to Conduct InvestigationProgress Meetings Every Evening

Party DesignationOrganizations are Named as Parties Because they Have Special Knowledge or Resources that the Board Needs to Complete the Investigation.Party Representatives Can Not Be Lawyers or Insurers & Must Have Technical Qualifications

Parties to investigationFlorida FWCRegion supervisor5 investigators, 1 PAOU.S. Coast Guard Senior investigating officer (LT)Inspections division chief (LT)

Causal Issues – proximate causeHuman factorsDeceased sitting “operator”Lacked training and experience, inattention, view obstructions, line of sight, distractionsSurviving standing “operator”Intoxication, inattention, distractionsOwner of recordResponsibility for oversight of vessel operation, intoxication

NTSB AuthorityIssues SubpoenasTake Testimony Under OathMay Enter Any Property Where Accident Has OccurredCopy Pertinent Files and DocumentsOrder Autopsy of Accident VictimsTest any component of the wreckage

NTSB ResourcesMaterials laboratoryTransportation disaster assistance/ family assistanceMedical evaluation of autopsies and tox tests. MD on staffCommercial vessel A/I experienceWeather data retrieval and analysisData recorder recovery and analysisHuman factors specialistTox laboratory

State Capability and ResourcesAccident reconstruction and documentation expertiseLocal knowledgeSite securityLogistical support

Challenges to CooperationEarly communications and coordinationNon-criminal processLawyers/due processOverlapping investigation needsInterviewsData and evidence collectionAccess to accident siteLimited opportunity to investigate recreational boating accidents

ChallengesPublic dissemination of informationConflicting A/I protocolsSafety vs. law enforcementRights of intervieweesWarningsImmunitySelf-incriminationRepresentationCollection of evidence (rules of, chain of custody)Transparency of NTSB investigation

ConclusionWhy is mutual cooperation important to each of us?

Judicial Process and NTSBBoard employees may testify once (through deposition or interrogatories) for all civil litigations (49 CFR § 835.5)NTSB makes available unique factual information not otherwise available NTSB Board Reports may not be used or admitted into evidence in any action for damages arising from an accident (49 CFR § 835.3) Interaction with United States Attorneys is rare and limited General Counsel determines if staff may testify in criminal matter (49 CFR § 835.10)

NTSB and the Coast GuardJoint Regulations (49 CFR Part 850) NTSB – USCG Memorandum of Understanding, signed December 19, 2008Coast Guard a party to NTSB-led investigationsNTSB

Joint Regulations (49 CFR Part 850)

NTSB – USCG Memorandum of Understanding, signed December 19, 2008

Coast Guard a party to NTSB-led investigations

NTSB Has Three Options:Request the Coast Guard to Investigate On Behalf of the Safety Board With No NTSB Participation, orConduct a Joint Investigation With the Coast Guard Under Coast Guard Rules, orConduct an Independent Investigation Under NTSB Rule.

Request the Coast Guard to Investigate On Behalf of the Safety Board With No NTSB Participation, or

Conduct a Joint Investigation With the Coast Guard Under Coast Guard Rules, or

Conduct an Independent Investigation Under NTSB Rule.

Investigating Marine AccidentsEntire Marine Investigative Staff Works Out of Washington, D.C. HeadquartersCurrent Marine Technical Staff - PersonsMaster MarinersLicensed Marine EngineersNaval ArchitectsHuman PerformanceSurvival Factors